Archive for July, 2011

About a third of unnecessary ER use is categorized as “avoidable,” followed by visits from high utilizers, often referred to as ‘frequent flyers,’ who generate 29 percent of avoidable use, according to a recent HIN survey on reducing avoidable ER use. Survey respondents include physicians in many strategies to reduce avoidable ER use. For example, 63 percent of respondents alert primary care physicians (PCPs) to ED visits by recently discharged patients.

Establish an alliance of hospital and post-hospital providers to address avoidable readmissions and ED visits. Collaborate between cross-spectrum of services to break down silos of healthcare providers;

Allow PCP to cover absence of an employee from the first day off work, not from first day seen in medical office. EDs are a tool of convenience prior to PCP appointment;

Use a transfer call center with the hospitalist assuming admission on unassigned patients;

Work with providers to have “walk-in” or urgent care slots built into daily appointment templates;

Facilitate PCP group relationships with the Regional Health Information Organization (RHIO), in which ERs of various hospitals collaborate;

Introduce coaching module follow-up for 30 days post-discharge;

Develop community care plans that involve the frequent flyer patient, PCP and ED. Then develop an agreed-upon coordinated plan of care. The first priority is that the patient contacts the PCP before entering the ED. If the patient still presents to the ED, it is the goal of the ED case manager to contact the PCP and discuss better options;

“You can’t manage what you can’t measure!” reports one respondent to our live survey on health registry use. At the midpoint of the survey response period, diabetes patients are the principal targets of registries, report three-fourths of respondents. The same percentage expect that registries will eventually be required for Medicare or Medicaid reimbursement.

Registries in general; why bother? You hear about them and think that they’re something that you read about in studies or something that the state maintains, but they’re actually useful for you. They help you get an idea of specific populations of patients you care for. One of the things that the ACO and value-based healthcare is driving for, in addition to taking care of the patient in front of you, is to start thinking about groups of patients that you’re caring for, higher risk groups. So it’s useful clinically right from the beginning to think about a bigger picture view of your practice.

First, the NCQA and the patient-centered medical home actually require that you develop registries. A secret is a registry is another name for a list of patients who meet a certain criteria, usually for a high risk or an important condition. If you think about it that way it’s really not as intimidating. We’ve been a Level 3 Medical Home for about two years and registries are a requirement to get an idea of the important populations that you care for.

A second tangible benefit of the use of registries is in quality efforts, specifically in identifying groups of patients who need certain tests performed. A very seasonal registry that we have are the people that are due and eligible for flu shots. That registry or that group changes every year but we’re able to gather this group with a criteria and then reach out to them with an automated call script through our automated appointment reminder system.

A third important use of registries is risk; identifying people that are at high risk for bad things happening to them or spending money if you’re in a more risk-based situation. About two years ago, we formed our own malpractice company, our own risk retention group and we think about risk a lot more since it’s more tangible and real to all the partners that they’re not more on the hook for things that happen. Registries are useful in that capacity.

And finally, registries will play a major part in the accountable care organization (ACO). CMS is currently headed by the individual who created the Institute for Health Improvement’s Triple AIM: the experience of care (how the patient thinks you are doing); the per capita cost (how much you’re spending to do it so the value you’re delivering for what you’re getting); and looking at the whole population, not just individual patients. Certainly the registry is a direct hit on that pillar.

Almost a third of people in 12 states were obese in 2010, according to a new CDC report. Also, no state met the national Healthy People 2010 goal to lower the prevalence of obesity to 15 percent.

Our country in general and the healthcare industry in particular are hungry for obesity and weight management interventions, according to this CDC report and recent market research by the Healthcare Intelligence Network. Among the program challenges reported by 130 survey respondents was an inability to respond to overwhelming demand for obesity and weight management programs. Some even had to limit the number of participants in programs.

The most revealing trend has been the increase in obesity and weight control programs for children and adolescents — up sevenfold in the two years since we last surveyed on this topic. Payors in particular are focused on these early interventions, launching obesity and weight management programs in schools, including family in weight management education efforts, and dedicating case management resources to this population.

Healthcare providers also are taking on a larger role, as more organizations rely on physician referrals to recognize weight and obesity issues in patients and educate patients on nutrition, the value of physical exercise and its potential to trigger more serious and costly health complications.

The survey results indicate that it doesn’t seem to take much to motivate and engage participants, and that efforts in this area need to be fun. Many are modeling competitions on television’s popular “Biggest Loser” program. While there are some high-priced incentives for profound weight loss, it seems that a $25 gift card or a discount to a weight management program or gym is enough to get people moving in the right direction.

Even one miss on a hospital core measure can mean the loss of a significant amount of money for an organization, says Dr. Steven Berkowitz, MD, president SMB Health Consulting and former chief medical officer of St. David’s Healthcare System.

With the upcoming changes to Medicare reimbursement, hospitals are no longer focusing on core measures for quality, but for the financial bottom line, said Dr. Berkowitz. Therefore, it is vital to identify every core measure patient.

Most of the core measure patients come out of the emergency room (ER), said Dr. Berkowitz. This presents the opportunity to identify them as heart failure (HF), acute myocardial infarction (AMI) and pneumonia patients.

One strategy to rapidly identify core measure patients is to note every direct hospital admission to the concurrent reviewer so that the patient is on the potential core measure radar screen before they even hit the floor of the hospital.

In addition, each measure must be reviewed individually. Ownership should be assigned to different people for each measure. According to Dr. Berkowitz, everyone should know whether they are the one responsible or not. This allows for policies and procedures to be put in place that create accountability. For example, if a nurse misses a core measure, that nurse is accountable to the CEO of the hospital to explain why that measure was missed.

According to Dr. Berkowitz, it is important to check, check and recheck the core measures. When looking at each measure, such as HF, ask detailed questions like: How do we identify the patient? How do we make sure that the patients receive the packet per discharge instructions? How do we confirm these packets are matched up with the physician’s discharge?

It is necessary to break the process down into everything that needs to be done and who is responsible for following and identifying the necessary patient and making sure it is done in a timely manner, Dr. Berkowitz explained. Listen to an interview with Dr. Berkowitz.

Women of all ages and backgrounds will benefit if eight new free preventive health services are added to the Patient Protection and Affordable Care Act (PPACA) of 2010. Birth control, gestational diabetes screening, DNA testing for cervical cancer and domestic violence counseling are among the recommendations in a new report from the Institute of Medicine (IOM).

Low health literacy results in more frequent hospitalizations and a higher risk of death, according to a recent study from RTI International-University of North Carolina. The study found that 77 million English-speaking adults in the United States are unable to understand and use basic health information. Limited health literacy rates are higher among seniors, minorities, lower-income Americans and those with less than a high school education.

In merger news this past week, Express Scripts and Medco agreed to a $29 billion merger deal. Healthcare consumers and the nation’s drug stores will be watching the impact of the merger closely. These stories and more in this week’s Healthcare Business Weekly Update.

By risk-stratifying patients at high risk for hospitalizations and re-hospitalizations into a coordinated, multi-disciplinarian program, HealthCare Partners Medical Group of California has significantly reduced readmissions for its patients, reports Dr. Stuart Levine, MHA, corporate medical director for HealthCare Partners Medical Group.

Targeting high-risk patients can be difficult but necessary, explained Levine during the recent webinar Reducing Readmissions Through Multi-Disciplinary Post-Discharge Support. The HealthCare Partners Medical Group risk-stratification program is driven by type of disease, complexity of disease and ROI. By utilizing a predictive modeling tool to separate the patient’s conditions into hierarchical categories, the patients are placed into the medical home that best suits their needs.

The medical homes are separated into hospice and palliative care, home care, an end-stage renal disease (ESRD) medical home program, comprehensive care centers and post-discharge clinics. A significant amount of the care is telephonic, with intermittent face-to-face care, and patients with specific diseases have home monitoring devices as well.

According to Dr. Levine, the patient delivery system is based on health education, prevention and chronic-care management for most patients. Risk-stratification pays off for the patient and the provider during patient discharge and handoff. On a daily basis, there are coordination calls between all of the high-risk patients, the hospitals and other high-risk practitioners, as well as between the primary doctors and location to which the patient is discharged.

The specialists act as consultants, oftentimes going on-site to the clinics to practice their specialty care to ensure the handoff between primary care and specialty care is efficient, Levine explained. Listen to an interview with Dr. Levine.

Two recent studies focused on diabetes patients reveal that the saying “There’s no place like home” may be true — in this case, it’s a patient-centered medical home (PCMH).

The PCMH model of care has always focused on improving care quality and reducing costs for the chronically ill. Now, the PCMH has been found to increase the percentage of diabetes patients who achieve goals that reduce their sickness and death rates, according to health researchers.

A report from the eHealth Initiative found that using electronic health records (EHRs) in medical homes to coordinate care resulted in numerous process improvements for patients with Type 2 diabetes and heart disease in a medical home.

The initiative reported improvements in provider-patient communications, intra-office coordination, EHR use, care planning, patient coaching, specialist referrals and several other areas. The care plan enabled by the EHR allowed researchers to streamline the care process for the patients and more efficiently track their progres:

At one site, six separate cardiology referral forms were used before the project began. Following the intervention a single form was developed and formatted within the EHR, said Victor Villagra, MD, president of Health and Technology Vector.

In a second study, Pennsylvania researchers say the key of the PCMH is to make physicians not only look at individuals, but at their patient population in general.

In PCMH, medical practices learn to work together as a team, coordinating care centered on the patients’ needs. The researchers report a significant improvement in adherence to evidenced-based care guidelines and in clinical outcomes. In one year, the number of patients with better LDL levels, better blood pressure and or lower A1c levels increased. The number of patients receiving yearly foot exams, eye exams and pneumonia and influenza vaccines also increased, according to a Penn State College of Medicine press release.

Pennsylvania leads the nation in implementing the PCMH, based on the chronic-care model (CCM) of care, which promises to improve health and reduce costs of care. This type of care attempts to move from a reactive approach to a focus on long-term problems in healthcare delivery.

New market research shows that one third of medical homes will join an ACO in the next 12 months. And more than half of those interviewed by the Healthcare Intelligence Network for our fifth annual survey on patient-centered medical homes said they had already established a medical home for their population. The PCMH is a favored model of integrated care delivery and a cornerstone of accountable care — two core elements of healthcare reform. More in this issue.

About $216 million nationally is spent each year managing drug
shortages in the hospital setting, with three drugs in particular
affecting over 80 percent of health systems, says a new study
released by the American Society of Health-System Pharmacists
(ASHP). The problem is not only increasing hospital costs but
harming patient care: nearly a third of the 353 pharmacy directors
surveyed said they had to pull clinical staff to manage the crisis.

More than $300 billion each year is spent on care for dual-eligibles,
the 9 million Americans currently receiving both Medicare and
Medicaid benefits. HHS hopes to lower these costs — and improve
care — with three new initiatives: financial models to better align
finances between the agencies; a quality care program for nursing
home residents, and a resource center program.

Telemedicine continues to serve the underserved. A new remote
monitoring pilot project from the University of Utah seeks to help the
chronically ill who are unable to reach traditional care facilities easily
on a regular basis. The project will feature a centralized care
coordinator, four clinics monitoring 15 to 20 patients each and two
locations using kiosks to monitor another 30 patients each. Read more in this week’s Healthcare Business Weekly Update.

Or how about a FASTPASS® card, good for one free pass to the front of the line for a flu shot?

Or some fairy tale characters to keep the kids busy?

Disney believes it can teach hospital and healthcare executives how to meet and exceed their patients’ expectations. The mega theme park is introducing a new program, called “Building a Culture of Healthcare Excellence,” and it incorporates Disney’s 5 leading philosophies:

The program, created and presented by the Disney Institute, is designed to help healthcare administrators, physicians, nurses and other manager-level personnel.

The timing of the program is designed to coincide with the HCAHPS’s nationally standardized survey that allows consumers to compare hospitals based on how effectively they satisfy patient expectations. Starting this month, hospitals are required to publicly report the results of these surveys, which are published by the CMS on its Hospital Compare website.

In line with this, the Disney Institute’s program looks beyond the clinical and technical and focuses instead on the entire patient experience, including interactions with hospital staff at all levels, and amenities that can help the patient feel more comfortable, such as private rooms and on-demand dining services.

It’s an area that many healthcare executives admit they need to improve. According to the results from our recent Improving Patient Experience and Satisfaction survey, nearly 85 percent of respondents said they were not happy with their organization’s patient satisfaction scores as currently posted on the CMS Hospital Compare site. Communication and quality of care were the areas that they felt were most important to their patients and members. But more than half of them said communication was where they felt they needed the most improvement in, with access and waiting times coming in second.

So maybe we can learn a thing or two from the company that makes thousands of people happy every day.

Case managers focus on the highest risk patients in that practice. They may or may not have common chronic conditions such as diabetes or heart failure (HF) but they may just be frail elderly who will have dementia or who were just getting frailer and cannot live alone safely in their current condition. We focus on the highest risk patients at that site and what’s driving the conditions or the experience for the patient. For example, if it is HF, we work with the patients and the provider to design a plan of care that’s going to get at that HF. What do they need to do when their weight starts to go up? Do we need home care involved? If they’re hospitalized, what do they need to know now to prevent a hospital readmission? We focus on the driver of their conditions.

Transitions of care are another core component of the case managers. They get notified about every admission and discharge from their site, and outreach telephonically to every discharged patient within 24 to 48 hours. They focus on a series of issues: medication reconciliation and making sure that what was changed, adjusted or added in the hospital is accounted for on the outpatient side. Has the patient filled their prescriptions? Do they have the money to get them? Do they have access to the pharmacy to get them filled? We found early on that patients who get new prescriptions take them home but do not fill them until they got their PCP’s blessing. We also found many medication errors, such as the patient at home who was on Metoprolol but who was put on Topherol in the hospital — two beta blockers or two ACE inhibitors. Case managers make sure that there is a clear understanding of what the patient is taking or should be taking at home. Medication reconciliation has been a huge focus and a huge win for us.

We also focus on:

Is the patient safe in their home?

Are they well enough to be caring for themselves?

If not, do they have good, strong social supports to help take care of them in the house?

Download this FREE report for data on the top clinical targets of healthcare case managers; the top means of identifying and stratifying individuals for case management; and the most common locations of embedded or colocated case managers.